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Sindrome del tunnel carpale: cosa può fare la fisioterapia per aiutare?

Autore: Giacomo Ziopponi Fisioterapista

Cosa è il tunnel carpale (e la sua sindrome?)

Il tunnel carpale è uno spazio delimitato dalle ossa del carpo (cioè il polso) e dal legamento carpale trasverso, che passa al di sopra di esse facendo da ponte tra quelle che prendo il nome di scafoide e trapezoide dal lato radiale della mano (quello con il pollice) e quelle sul lato ulnare (quello del mignolo) che si chiamano invece pisiforme e uncinato. All’interno di questo spazio passano diverse strutture importanti per il funzionamento della mano, in primis i tendini di ben nove muscoli, che ci consentono di articolare le dita, e il nervo mediano, che ha il ruolo di portare i comandi dal cervello ai muscoli e le gli stimoli dalla mano al cervello.

Risultato immagine per tunnel carpale

Nello specifico il nervo mediano è responsabile dell’innervazione della parte palmare della mano e delle prime tre dita, oltre che dell’avambraccio nella sua porzione frontale. Il nervo si divide dagli altri a livello del plesso brachiale e trae origine dalle radici cervicali C5 C6 e C7.

La sindrome del tunnel carpale si manifesta quando, a causa di un restringimento dello spazio disponibile all’interno di questa struttura, il nervo mediano viene compresso e inizia a manifestare sintomi tra cui dolore, formicolio e bruciore sono fra i più frequenti. I nervi sono infatti strutture che risentono particolarmente delle condizioni di compressione in quanto questa genera ischemia, cioè mancanza di sangue (e di conseguenza di ossigeno); essendo il sistema nervoso ciò che ci consente di interfacciarci con il mondo è logico che sia molto allarmato nel momento in cui si trova in situazioni di possibile compromissione.

 Altri sintomi possono includere riduzione della forza di presa della mano, difficoltà nel muovere il pollice, dolore diffuso lungo l’avambraccio e in alcuni casi anche alterazioni della sudorazione e della circolazione sanguigna della mano. Questo perché come abbiamo detto il nervo è responsabile in parte anche della sensibilità dell’avambraccio e cambiamenti nel suo funzionamento dovuti alla compressione possono alterare anche la regolazione della circolazione e sudorazione, visto che queste sono risposte che il corpo mette in atto in base agli input alterati che il nervo si trova a trasmettere.

Chi è maggiormente colpito? E come si capisce?

La sindrome del tunnel carpale è la neuropatia compressiva più frequente in assoluto, e può colpire chiunque, ma la maggior parte dei casi si riscontrano in persone di età medio avanzata (45-60 anni) e nelle donne; inoltre è più diffusa nella popolazione caucasica.

Esistono anche dei fattori che possono incrementare il rischio: 

  • alcune patologie croniche come artrite reumatoide, gotta, la ritenzione idrica, l’insufficienza renale, il diabete e l’obesità;
  • la gravidanza (probabilmente a causa della ritenzione idrica tipica degli ultimi mesi di gestazione);
  • spazio nel tunnel carpale ridotto per caratteristiche anatomiche genetiche o dovute a traumi o fratture;
  • è ipotizzata (ma non ancora certa) una predisposizione professionale per videoterminalisti, lavoratori che usano strumenti vibranti e esposti a movimenti ripetitivi, come ad esempio operai che usano martelli pneumatici o musicisti che hanno un carico ripetitivo sulle mani.

La diagnosi della sindrome del tunnel carpale è tipicamente clinica: questo significa che di solito dalla descrizione dei sintomi, dalla anamnesi (la raccolta dei dati relativi alla salute generale del paziente) e da un esame obiettivo attento il medico riesce ade identificare la situazione senza bisogno di ulteriori esami. In caso di dubbi, può essere utile un’elettromiografia per valutare la conduzione nervosa.

Due semplici test clinici molto utilizzati per la diagnosi sono il test di Tinel e il test di Phalen:

  • test di Tinel: è una manovra di stimolazione usata in molte neuropatie periferiche e consiste nell’effettuare delle percussioni in un punto in cui il nervo è esposto e si valuta la presenza in risposta allo stimolo di sensazioni di formicolio, punture di spilli o scariche elettriche, tipiche del dolore neurale, nella zona innervata. Nello specifico, per il tunnel carpale la manovra viene applicata a livello del polso e si valuta la presenza di sintomi solitamente sulla superficie palmare della mano. 
Tinel Sign of the Wrist | Carpal Tunnel Syndrome Assessment
  • test di Phalen e Phalen inverso: entrambe queste manovre sono provocative. Viene richiesto al paziente di mettersi con i dorsi delle mani a contatto e gli avambracci orizzontali, andando così a comprimere lo spazio in cui passa il nervo. Può essere effettuato anche in modo inverso, con i palmi a contatto. In questo test si valuta la comparsa dei sintomi familiari del paziente al mantenimento della posizione per 60 secondi. Esistono inoltre varianti in cui al test viene abbinata una valutazione della sensibilità delle dita innervate dal nervo mediano (primo, secondo, terzo e parte mediale del quarto dito)
Phalen's Test & Reverse Phalen's Test: Mobile Physio

Come può essere utile un fisioterapista in caso di sindrome di tunnel carpale?

In tutte le neuropatie da intrappolamento la fisioterapia può ricoprire un ruolo importante nella gestione dei sintomi. Nello specifico il fisioterapista può, attraverso una attenta valutazione locale e di tutti i distretti interessati dal nervo in questione, elaborare degli esercizi e delle strategie che consentano di mantenerlo più in movimento e favorirne una desensibilizzazione. La sindrome del tunnel carpale, soprattutto nelle sue fasi iniziali e moderate, non fa eccezione. La valutazione permette di identificare se il nervo può beneficiare di essere trattato e mosso anche a distanza dal polso: questo è vero soprattutto in quei casi che riscontrano dolore anche in altre zone come il collo o la spalla o che lo hanno riscontrato in passato. Dobbiamo ricordare che il dolore legato ad un nervo può essere influenzato in negativo o in positivo dal movimento di tutto quello che sta a monte e a valle del punto principale dove si avverte il sintomo. 

NEURODINAMICA

Un approccio terapeutico utile che tiene ben conto di questa circostanza è la neurodinamica. Vengono fatti dei test per portare in tensione i nervi periferici e determinare quanto siano sensibili allo stiramento e, se giudicato opportuno, si possono eseguire mobilizzazioni delle strutture che circondano il nervo a vari livelli: sicuramente il polso è importante, ma anche spalla e collo possono influire. È importante ricordare che questi test non servono alla diagnosi, bensì solo a determinare il livello di sensibilità meccanica del nervo ad uno stimolo di tensione. Proprio per questo è utile effettuarli prima sul lato non interessato da patologia. Sulla base dei risultati del test, del trattamento e del ri-test, vengono inoltre dati esercizi al paziente per stimolare il movimento del nervo, con intensità gradualmente crescente nel corso delle sedute. 

Questo approccio si è rivelato abbastanza utile per tenere sotto controllo il dolore soprattutto nel breve e medio termine, ma non ha grossi risultati sul deficit di forza  e la perdita di funzionalità che la sindrome del tunnel carpale può portare con sé: per queste un importante alleato nel percorso riabilitativo è l’esercizio terapeutico.

Neurodynamic Mobilization can be either, sliding (left) or tensioning... |  Download Scientific Diagram

Esempio di manovra neurodinamica: tutto il nervo viene portato in allungamento nella figura a destra. La figura a sinistra rappresenta invece un lavoro a carico tensionale ridotto, più utile nelle fasi più acute di problematiche neurali.

RICONDIZIONAMENTO DEGLI ARTI SUPERIORI

Attraverso un rinforzo progressivo non solo della mano, ma anche di tutte le strutture muscolari degli arti superiori, si può intervenire sul deficit di forza e sulla riduzione della funzionalità legata alla sindrome del tunnel carpale; qualora inoltre il nervo sia irritato non solo a causa della compressione al polso, ma anche dalle posture e dai movimenti ripetitivi, il fatto di fare esercizi contro resistenza o anche semplicemente nuovi e muoversi in modo più variabile può influire positivamente sui sintomi.

Gli esercizi che trovano spazio in questo approccio variano naturalmente a seconda della situazione e delle esigenze del paziente. In generale possiamo trovare:

  • esercizi di mobilità: saranno utili a riabituare il polso a muoversi in tutto il suo arco di movimento e a facilitare il movimento delle altre articolazioni del braccio se opportuno;
  • esercizi di rinforzo selettivo della mano e del polso: con questi si va a stimolare il recupero della forza di presa e dei movimenti del polso;
  • esercizi di forza globale per il braccio: hanno il pregio di incoraggiare variabilità di movimento, favoriscono l’irrorazione del nervo e stimolano il recupero della forza di presa, che nella sindrome del tunnel carpale può ridursi;
  • esercizi di controllo motorio fine: perché se è vero che rinforzare è utile, è altrettanto vero che spesso chi soffre di problemi al tunnel carpale è in difficoltà anche in attività che richiedono relativamente poca forza ma molto controllo, come scrivere, dipingere, suonare uno strumento. Attraverso esercizi via via più specifici si va a cercare un recupero delle attività limitate dai sintomi;
  • riesposizione graduale alle attività: è naturale in un percorso di questo tipo dover inizialmente rimuovere o modificare le azioni che esacerbano maggiormente i sintomi. Nel corso del recupero però sarà estremamente importante reintrodurle in maniera tollerabile per evitare che si instauri un comportamento di evitamento e di paura nei confronti di queste attività. Per fare ciò si utilizzano sia strategie di autogestione da parte del paziente sia esercizi che vanno a mimare l’attività stessa, o che possono essere funzionali ad essa.

Quanto sappiamo davvero di come funziona la sindrome del tunnel carpale?

Da un punto di vista fisiopatologico cosa accade in una sindrome del tunnel carpale sembra abbastanza chiaro: a causa di molti fattori contribuenti fra cui le attività svolte dal paziente, il suo stato di salute generale e le sue interazioni quotifdiane, può determinarsi un aumento di pressione all’interno del tunnel carpale. Questo aumento pressorio può generare sintomi che possono poi sfociare anche in danni maggiori al nervo come neuroaprassia (perdita di funzione) assonotmesi o neurotmesi (lesione di alcune o tutte le fibre nervose). Anche i legamenti che delimitano lo spazio e i tendini che vi scorrono possono andare ad essere interessati, riducendo la loro funzionalità e il loro ruolo di stabilizzazione.

Dal punto di vista dei meccanismi che innescano e regolano l’andamento dei sintomi le conoscenze oggi a disposizione sono meno limpide. Sappiamo ad esempio che nei casi in cui la compressione e la perdita di capacità conduttiva del nervo siano di entità importante, la chirurgia seguita da fisioterapia per recuperare la mobilità è il trattamento migliore. Un aspetto che però fa riflettere su come il nostro sistema nervoso elabori il dolore però emerge proprio da alcuni studi fatti sull’intervento chirurgico. La sindrome del tunnel carpale può presentarsi anche in maniera bilaterale, cioè in entrambe le mani contemporaneamente. È interessante come sia stato rilevato che in alcuni di questi casi l’intervento chirurgico di uno solo dei due polsi risulti risolutivo della sintomatologia per entrambi. È difficile al momento dare un’esatta spiegazione a questo fenomeno: quello che sappiamo è che il dolore, soprattutto quello direttamente legato ai nervi è un fenomeno molto complesso, che può essere influenzato da molteplici fattori. Compito del fisioterapista è proprio aiutare chi si rivolge a lui ad esplorare questi fattori e trovare il modo di recuperare un livello soddisfacente di attività.

Autore: Giacomo Zipponi Fisioterapista

Fisioterapia e Osteopatia a Brescia

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